Provider Demographics
NPI:1821796087
Name:DIAMONDS IN ROUGH MENTORING PROGRAM
Entity Type:Organization
Organization Name:DIAMONDS IN ROUGH MENTORING PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-966-2271
Mailing Address - Street 1:3787 PENDENT LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-3479
Mailing Address - Country:US
Mailing Address - Phone:614-966-2271
Mailing Address - Fax:
Practice Address - Street 1:3787 PENDENT LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-3479
Practice Address - Country:US
Practice Address - Phone:614-966-2271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty